臨床醫療倫理 ethics in clinical practice

臨床醫療倫理臨床醫療倫理Ethics in Clinical PracticeEthics in Clinical Practice

Ming-Been Lee, M.D.Ming-Been Lee, M.D.Departments of Psychiatry and Social MedicineDepartments of Psychiatry and Social Medicine

College of Medicine College of Medicine National Taiwan University National Taiwan University

醫學的真諦醫學的真諦

醫學是關係的科學◎◎ 病病人人為中心為中心 ◎ ◎ 家庭為單位家庭為單位 ◎ ◎ 社區為基礎 社區為基礎

醫學以醫學以人文人文為基礎為基礎傳統傳統 :: 人的人的尊嚴尊嚴、、利益利益與與價值價值現代現代 :: 人與萬物人與萬物和諧共生和諧共生

優質的醫療優質的醫療專業技術專業技術專業倫理專業倫理專業溝通專業溝通聖聖

TerminologyTerminologyMoralityMoralityEthicsEthicsLawLawBioethicsBioethicsMedical EthicsMedical Ethics

ObjectivesObjectives of Medical Ethics Education: To Teachof Medical Ethics Education: To Teach

1. 1. HumanisticHumanistic and ethical aspects of medical career; and ethical aspects of medical career;

2. Personal moral and 2. Personal moral and professional professional moral moral commitments;commitments;3. Foundation of philosophical, social, and 3. Foundation of philosophical, social, and legal knowledge; legal knowledge; 4. Medical4. Medical reasoning reasoning;;

5. 5. Interactional skillsInteractional skills to apply insight, knowledge and to apply insight, knowledge and reasoning to clinical care.reasoning to clinical care.

醫學倫理理論、原則與規則醫學倫理理論、原則與規則理論理論 原則原則 規則規則

效益效益論論(Utilitarianism)(Utilitarianism)

行善行善(beneficence)(beneficence)

1.1. 關懷，保護病人的權利關懷，保護病人的權利2.2. 預防及排除可能的傷害預防及排除可能的傷害3.3. 幫助他人幫助他人，，造福人群造福人群不傷害不傷害

(nonmalefice(nonmaleficence)nce)

1.1. 不能傷 害病人不能傷 害病人2.2. 不能侵害病人的權利或 不能侵害病人的權利或 幸福幸福3.3. 平衡利害得失平衡利害得失，，使痛苦 使痛苦 減至最低減至最低

醫學倫理理論、原則與規則醫學倫理理論、原則與規則理論理論 原則原則 規則規則

義務論義務論(Deontological (Deontological Theory)Theory)

公正公正(justice)(justice)

1.1. 分配正義分配正義 2. 2. 福利正義 福利正義 3. 3. 法律正義法律正義

尊重自主尊重自主( respect for ( respect for autonomyautonomy))

1.1. 誠實誠實2.2. 守密 守密 3.3. 知情同意知情同意4.4. 尊重隱私尊重隱私

Medical Ethics: PrinciplesMedical Ethics: Principles

1.1. AAutonomyutonomy2. 2. BeneficenceBeneficence3. 3. Non-maleficenceNon-maleficence4. Justice4. Justice

Medical Ethics: RulesMedical Ethics: RulesInformed ConsentInformed ConsentConfidentialityConfidentialityTruth tellingTruth tellingVeracityVeracityPrivacy: LimitedPrivacy: Limited

Parties Involved in Clinical EthicsParties Involved in Clinical Ethics

Staff-patientsStaff-patients Staff-Staff-familyfamily Staff-Staff-staffstaff Staff-societyStaff-society Third partiesThird parties

Health Care EthicsHealth Care Ethics Model of Staff-Patient relationship: a Model of Staff-Patient relationship: a TeamTeam.. Good mannersGood manners Keep secret: third parties, legal, using Keep secret: third parties, legal, using

computerscomputersInformed decision makingInformed decision making Patient’s right and responsibilityPatient’s right and responsibility Justice: Resource allocation, Minimal justice Justice: Resource allocation, Minimal justice High-tech medicineHigh-tech medicine Special issues: AIDS/ICU/organ transplantationSpecial issues: AIDS/ICU/organ transplantation

Clinical EthicsClinical Ethics: Three : Three Obligations to PatientsObligations to Patients

Give the best care that we Give the best care that we cancan

Be honestBe honestBe trustworthyBe trustworthy

Principle of AutonomyPrinciple of AutonomyRationalRational individuals should be permitted to be individuals should be permitted to be

self-determinedself-determined..

Patient’s autonomy VS rights and needs of Patient’s autonomy VS rights and needs of othersothers . .

Respect for AutonomyRespect for AutonomyPatient’s Patient’s body integritybody integrity..Patient’s control over Patient’s control over touching, manipulatitouching, manipulation, invasion, medication, or other intervenon, invasion, medication, or other intervention.tion.Patient’s right to Patient’s right to authorizeauthorize beneficient act. beneficient act.

Informed ConsentInformed ConsentShow Show respectrespect for self-determination.for self-determination.Function as a Function as a correctivecorrective process to process to

paternalism.paternalism.Provide opportunity and encouragement Provide opportunity and encouragement

to become more active in to become more active in decision decision makingmaking..

A A PROCESSPROCESS rather than a rather than a DocumentDocument..

Consent ProcessConsent ProcessProvision of Provision of informationinformationComprehensionComprehensionVoluntarinessVoluntarinessConsentConsent ActiveActive authorization rather than passive authorization rather than passive consentconsent

Required DiscussionRequired Discussion 1. Define problems1. Define problems 2. Exact 2. Exact nature nature of proposed treatmentof proposed treatment 3. 3. AlternativesAlternatives 4. 4. PrognosisPrognosis with and without treatment with and without treatment 5. 5. RisksRisks and benefits of treatment and and benefits of treatment and alternativesalternatives 6. Serious risks even if unlikely 6. Serious risks even if unlikely 7. Any question7. Any question patient patient may havemay have

General Process of Case AnalysisGeneral Process of Case Analysis 1. The Case: Review of fact.1. The Case: Review of fact. 2. Identification of 2. Identification of ethicalethical problems. problems. 3. Determine reasonable 3. Determine reasonable alternativesalternatives.. 4. Consider the option in relation to 4. Consider the option in relation to

ethical ethical PrinciplesPrinciples and and ContextContext.. 5. Propose a resolution.5. Propose a resolution. 6. Consider your position 6. Consider your position criticallycritically.. 7. Action required: Do the 7. Action required: Do the RIGHT RIGHT thing. thing.

SupportSupport

Interactional SkillsInteractional Skills

EducationEducation

常用的溝通技巧常用的溝通技巧關係關係的建立的建立非言語非言語溝通技巧溝通技巧言語言語溝通技巧溝通技巧

Establishment of Rapport

1.1. Listening Listening by 3rd ear by 3rd ear2. Sensitivity2. Sensitivity

3. 3. EmpathyEmpathy □ □ Concern □ Respect Concern □ Respect □ □ Acceptance □ GenuinenessAcceptance □ Genuineness □ □ Warmth □ UnderstandingWarmth □ Understanding

4. Confidence4. Confidence

非言語溝通技巧非言語溝通技巧 ●● 動作動作 ●● 空間空間 ●● 語助詞語助詞 ●● 觸摸觸摸

Major types of kinesic nonverMajor types of kinesic nonverbal communicationbal communication

Facial Expressions Gaze

Gestures

Supportive Technique

1. 1. AbreactionAbreaction 2. 2. ClarificationClarification 3. Praise3. Praise 4. Reassurance4. Reassurance

5. Suggestion5. Suggestion

醫療 醫療 態 態 度度能：專業技能、溝通合作能：專業技能、溝通合作心：心：同理心同理心 1. 1. 尊重尊重 4. 4. 體諒體諒 2. 2. 關懷關懷 5. 5. 坦誠坦誠 3. 3. 接納 接納 6. 6. 溫馨溫馨

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